Why Bioethics Should Be Concerned With Medically Unexplained Symptoms

Healthcare system barriers impacting the care of Canadians with myalgic encephalomyelitis: A scoping review

BACKGROUND

Myalgic encephalomyelitis (ME, also known as chronic fatigue syndrome or ME/CFS) is a debilitating, complex, multisystem illness. Developing a comprehensive understanding of the multiple and interconnected barriers to optimal care will help advance strategies and care models to improve quality of life for people living with ME in Canada.

OBJECTIVES

To: (1) identify and systematically map the available evidence; (2) investigate the design and conduct of research; (3) identify and categorize key characteristics; and (4) identify and analyse knowledge gaps related to healthcare system barriers for people living with ME in Canada.

METHODS

The protocol was preregistered in July 2022. Peer-reviewed and grey literature was searched, and patient partners retrieved additional records. Eligible records were Canadian, included people with ME/CFS and included data or synthesis relevant to healthcare system barriers.

RESULTS

In total, 1821 records were identified, 406 were reviewed in full, and 21 were included. Healthcare system barriers arose from an underlying lack of consensus and research on ME and ME care; the impact of long-standing stigma, disbelief, and sexism; inadequate or inconsistent healthcare provider education and training on ME; and the heterogeneity of care coordinated by family physicians.

CONCLUSIONS

People living with ME in Canada face significant barriers to care, though this has received relatively limited attention. This synthesis, which points to several areas for future research, can be used as a starting point for researchers, healthcare providers and decision-makers who are new to the area or encountering ME more frequently due to the COVID-19 pandemic.

Will psychology ever 'join hands' with disability studies? Opportunities and challenges in working towards structurally competent and disability-affirmative psychotherapy for energy limiting conditions

Despite sustained efforts among critically informed scholars to integrate thinking from disability studies into psychology, the psy disciplines continue to largely neglect the lived experience of disabled people and overlook disability as a form of social inequity and valued culture. In this article, I make a renewed case for integrating thinking from disability studies into psy, in particular within the psychotherapy professions and in the case of 'energy limiting conditions', a grass-roots concept that includes clinically and socially marginalised chronic illness such as Long COVID. Drawing on my experience as a disabled practitioner, and situating this within extant literature on disability and psy, I take an autoethnographic approach to exploring opportunities and challenges in bridging the interdisciplinary divide. I argue that unacknowledged institutional ableism within psy reproduces and is reinforced by physical and attitudinal barriers for disabled practitioners and service users, engendering under-representation of disability in psychotherapy professions and lacunae in disability-affirmative conceptual resources. Additionally, I propose that hermeneutical lacunae are bolstered by documented defensive clinical practices pertaining to disability. After discussing a wealth of opportunities for integration offered by disability studies, and noting the institutional failure within psy to embrace disability-related demographic and epistemic diversity, I question whether ongoing epistemic and social exclusions within the psy disciplines constitute a case of 'willful epistemic ableism'. Drawing on theorising vis-à-vis epistemic injustice and epistemologies of ignorance, I signal a form of systematic, actively maintained and structurally incentivised (motivated) non-knowing that results in collective failure among dominant groups to recognise established hermeneutical resources of the disabled community and allies. I conclude with suggestions of how this form of epistemic injustice might be mitigated.

Diagnosing by anticipation: Coordinating patient trajectories within and across social systems

Anticipation is a fundamental aspect of social life and, following Weber, the hallmark of social action-it means trying to take others' responses to our actions into account when acting. In this article, we propose and argue the relevance of anticipation to the sociological study of diagnosis. To that end, we introduce and elaborate on the concept of diagnosing by anticipation. To diagnose by anticipation is to consider diagnoses as cultural objects imbued with meaning, to anticipate how others will respond to their meaning in situ and to adapt the choice of diagnosis to secure a desired outcome. Unlike prognosis, which seeks to predict the development of a disease, diagnosing by anticipation entails seeking to predict the development of a case and the effect of different diagnostic categories on its trajectory. Analytically, diagnosing by anticipation therefore involves a shift in diagnostic footing, from trying to identify what the case is a case of, to trying to identify which diagnosis will yield the desired case trajectory. This shift also implies a stronger focus on the mundane organisational work of operating diagnostic systems and coordinating case trajectories within and across social systems, to the benefit of the sociology of diagnosis.

An account of medical treatment, with a preliminary account of medical conditions

In this article, I present a philosophical account of medical treatment. In support of this account, I offer a suggestive account of medical conditions. The account of medical treatment uses three desiderata to demarcate treatment from non-treatment. Namely, a treatment should: (1) be describable by features that enable it to be standardized and characterized as a discrete intervention, (2) target a specific medical condition, and (3) have the possibility of being effective. The account of medical conditions underlies the second desideratum and attempts to tie medical conditions closely to biological dysfunction, while also including some conditions for which biological dysfunction is absent or its presence uncertain. I offer a simple typology of treatments and show how the accounts are relevant to treatment effectiveness, disease, placebos, contested treatments, and treatment standardization.

The patient experience of medically unexplained symptoms: an existentialist analysis

This article explores the patient experience of medically unexplained symptoms (MUS) from an existentialist standpoint. Drawing on the work of Jean-Paul Sartre and Simone de Beauvoir, I explore their concepts of existential situation, existential project, authenticity, and praxis. I then analyze the situation of MUS patients in the current cultural and institutional context, elucidating that a lack of explanation for their symptoms puts MUS patients in an existential bind. I illustrate the effects of the experience of MUS on patients' existential projects. Last, I develop an ethical response in the existentialist tradition from the perspective of patients, providers, and society at large. I argue that there is a collective responsibility to foster conditions more conducive to authentic patient well-being and to improve the experience of patients with medically unexplained symptoms.

The Athletic ECG: A Line of Defense Against Misinterpretation

A 17-year-old competitive athlete was found to have a minor electrocardiogram abnormality on routine screening. Cardiac magnetic resonance revealed evidence of marked myocarditis, allowing a subsequent safe abstinence from exercise. The case highlights the importance of careful electrocardiogram interpretation, especially in athletes, where physiologic adaptive changes can pose a diagnostic challenge. (Level of Difficulty: Intermediate.).

(Dis)respect and shame in the context of 'medically unexplained' illness

A significant proportion of somatic symptoms remain, at present, medically unexplained. These symptoms are common, can affect any part of the body, and can result in a wide range of outcomes-from a minor, transient inconvenience to severe, chronic disability-but medical testing reveals no observable pathology. This paper explores two first-person accounts of so-called 'medically unexplained' illness: one that is published in a memoir, and the other produced during a semi-structured interview. Both texts are revelatory for their expression of shame in the context of encountering disrespect from healthcare professionals. The first section of my paper, clinical encounters, explores disrespect which, I argue, takes three interconnecting forms in these texts: disrespect for pain when it is seen as 'medically unexplained', disrespect for the patient's account of her own pain, and disrespect for the patient herself. The second section elucidates the shame that occurs as an affective and embodied consequence of encountering such disrespect. I claim that patients living with so-called 'medically unexplained' illnesses suffer a double burden. They endure both somatic and social suffering-not only their symptoms, but also disrespectful, traumatic and shame-inducing experiences of healthcare systems. I conclude with a reflection on the urgent need for changes in clinical training that could improve the quality of life for these patients, even in the absence of an explanation, treatment or cure for their symptoms.

Making space for disability studies within a structurally competent medical curriculum: reflections on long Covid

While critically informed approaches to medical education are increasingly advocated in literature, discussion of the potential role of disability studies in informing pedagogy and practice is largely lacking. The emergence of long Covid, alongside the strong possibility of a wave of covid-related disability, underlines an urgent need for medicine to develop more contextualised, nuanced and structurally competent understandings of chronic illness and disability. This article argues that the integration of thinking from disability studies into medical curricula offers a pathway to such understanding, informing a more equitable, holistic and patient-centred approach to practice. Further, a structurally competent, antiableist approach positions clinicians and patients as allies, working together within a structural context that constrains both parties. Such positioning may mitigate tensions within the clinical encounter, tensions that are well documented in the realm of marginalised chronic illness and disability. While the possibilities arising from a partnership between disability studies and medicine are numerous, the foci here are the social relational model of disability and the concept of psycho-emotional disablism, within a broader framework of critical disability studies. It is argued that inadequate healthcare provision and policy in the realm of long Covid can be understood as a form of structural and psycho-emotional disablism, arising from and reinforcing an ableist psychosocial imaginary permeated with neoliberal assumptions, and carrying a risk of furthering both disability and impairment. After considering long Covid through these particular lenses, the article concludes with a discussion of how a partnership between disability studies and a structurally competent approach to medical education might translate into practice.

Acknowledging and addressing the many ethical aspects of disease

Diseases change the life of individuals, the social status of groups, the obligations of professionals, and the welfare of nations. Disease classifications function as a demarcation of access to care, rights, and duties. Disease also fosters social stigmatization and discrimination, and is a personal, professional, and political matter. It raises a wide range of ethical issues that are of utmost importance in patient communication and education. Accordingly, the objective of this article is to present and discuss a range of basic ethical aspects of this core concept of medicine and health care. First and foremost, disease evokes compassion for the person suffering and induces a moral impetus to health professionals and health policy makers to avoid, eliminate or ameliorate disease. The concept of disease has many moral functions, especially with respect to attributing rights and obligations. Classifying something as disease also has implications for the status and prestige of the condition as well as for the attitudes and behavior towards people with the condition. Acknowledging such effects is crucial for avoiding discrimination and good communication. Moreover, different perspectives on disease can create conflicts between patients, professionals and policy makers. While expanding the concept of disease makes it possible to treat many more people for more conditions - earlier, it also poses ethical challenges of doing more harm than good, e.g., in overdiagnosis, overtreatment, and medicalization. Understanding these ethical issues can be difficult even for health professionals, and communicating them to patients is challenging, but crucial for making informed consent. Accordingly, acknowledging and addressing the many specific ethical aspects of disease is crucial for patient communication and education.

Sociology of Chronic Pain

Chronic pain is a common, costly, and consequential health problem. However, despite some important analytic contributions, sociological research on pain has not yet coalesced into a unified subfield. We present three interrelated bodies of evidence and illustrative new empirical findings using 2010 to 2018 National Health Interview Survey data to argue that pain should have a central role in sociological investigations of health. Specifically, we contend that (1) pain is a sensitive barometer of population health and well-being, (2) pain is emblematic of many contested and/or chronic conditions, and (3) pain and pain treatment reflect and have wide-ranging implications for public policy. Overall, whether pain is analyzed quantitatively or qualitatively-focusing on its distribution in the population, its social causes and consequences, or its subjective meanings for individuals-pain reflects social conditions, sociopolitical context, and health-related beliefs of a society. Pain is thus an important frontier for future sociological research.

Medicine's metaphysical morass: how confusion about dualism threatens public health

What position on dualism does medicine require? Our understanding of that question has been dictated by holism, as defined by the biopsychosocial model, since the late twentieth century. Unfortunately, holism was characterized at the start with confused definitions of 'dualism' and 'reductionism', and that problem has led to a deep, unrecognized conceptual split in the medical professions. Some insist that holism is a nonreductionist approach that aligns with some form of dualism, while others insist it's a reductionist view that sets out to eradicate dualism. It's important to consider each version. Nonreductive holism is philosophically consistent and clinically unproblematic. Reductive holism, however, is conceptually incoherent-yet it is the basis for the common idea that the boundary between medical and mental health disorders must be vague. When we trace that idea through to its implementation in medical practice, we find evidence that it compromises the safety of patient care in the large portion of cases where clinicians grapple with diagnosis at the boundary between psychiatry and medicine. Having established that medicine must embrace some form of nonreductionism, I argue that Chalmers' naturalistic dualism is a stronger prima facie candidate than the nonreductive alternatives. Regardless of which form of nonreductionism we prefer, some philosophical corrections are needed to give medicine a safe and coherent foundation.

Making and managing medical anomalies: Exploring the classification of 'medically unexplained symptoms'

This article explores the making and management of anomaly in scientific work, taking 'medically unexplained symptoms' (MUS) as its case. MUS is a category used to characterize health conditions that are widely held to be ambiguous, in terms of their nature, causes and treatment. It has been suggested that MUS is a 'wastebasket diagnosis'. However, although a powerful metaphor, it does neither the category nor the profession justice: Unlike waste in a wastebasket, unexplained symptoms are not discarded but contained, not ejected but managed. Rather than a 'wastebasket', I propose that we instead think about it as a 'junk drawer'. A junk drawer is an ordering device whose function is the containment of things we want to keep but have nowhere else to put. Based on a critical document analysis of the research literature on MUS (107 research articles from 10 medical journals, published 2001-2016), the article explores how the MUS category is constituted and managed as a junk drawer in medical science.

Illness and disease: an empirical-ethical viewpoint

Background

The concepts of disease, illness and sickness capture fundamentally different aspects of phenomena related to human ailments and healthcare. The philosophy and theory of medicine are making manifold efforts to capture the essence and normative implications of these concepts. In parallel, socio-empirical studies on patients’ understanding of their situation have yielded a comprehensive body of knowledge regarding subjective perspectives on health-related statuses. Although both scientific fields provide varied valuable insights, they have not been strongly linked to each other. Therefore, the article aims to scrutinise the normative-ethical implications of patient perspectives in building a bridge to the empirical ethics debates.

Main text

Three potential fields of tension between the illness and the disease perspective are presented. Consequently, findings from empirical research examining patient perspectives on illness are displayed and the practical implications and associated ethical issues which arise are discussed. This leads to the conclusion that an explicit and elaborate empirical-ethical methodology is needed to deal appropriately with the complex interaction between patients’ views and the medico-professional view of disease. Kon’s four-stage model of normative-empirical collaboration is then applied against the background of empirical data on patient perceptions. Starting from this exemplary approach, the article suggests employing empirical-ethical frameworks for further research on the conceptual and normative issues, as they help to integrate perspectives from the philosophy of medicine with socio-empirical research.

Conclusion

The combination of theoretical and empirical perspectives suggested contributes to a more nuanced discussion of the normative impact of patients’ actual understanding of illness. Further empirical research in this area would profit from explicitly considering potential ethical issues to avoid naturalistic fallacies or crypto-normative conclusions that may compromise healthcare practice. Vice versa, medico-theoretical debates could be enriched by integrating subjective views of those people who are immediately affected.